Delirium work-up and management

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Hey guys, I would like some input about delirium management and organic mental disorders in general: after you order the inital labs and images, and there is for instance a brain lesion [tumor, stroke, etc], do you call Neurology and sign off the case, or do you work together with them? I say that because I'm someone very interested in organic mental disorders and psychosis in general, but not that interested in the common neurosis (depression, anxiety), so I wonder if Neurology fits the bill better in these cases (to clarify, I am very uninterested in the PNS and most neuro pathologies, I'm just interested in them when they alter cognition and behavior).

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Hey guys, I would like some input about delirium management and organic mental disorders in general: after you order the inital labs and images, and there is for instance a brain lesion [tumor, stroke, etc], do you call Neurology and sign off the case, or do you work together with them? I say that because I'm someone very interested in organic mental disorders and psychosis in general, but not that interested in the common neurosis (depression, anxiety), so I wonder if Neurology fits the bill better in these cases (to clarify, I am very uninterested in the PNS and most neuro pathologies, I'm just interested in them when they alter cognition and behavior).

Psych --> consider fellowship in consult/liaison or neuropsychiatry.
 
Neuropsychiatry or behavioral neurology, rare academic fields from either direction and folks that almost always get 100% respect from both sides. Psychosis >>> strokes for me, so I would go the neuropsych route personally.
 
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Typically psychiatry is not involved in the work up of delirium (but we should be and by necessity may need to be if the patient is misdiagnosed or mismanaged). It would be very unusual for psychiatry to be consulted for workup and management of delirium explicitly. In fact it almost never happens unless its a really bad hospital. Instead, psychiatry is consulted for another reason (e.g. "rule/out late onset schizophrenia", "management of agitation", "decision making capacity", "patient trying to leave AMA", "suicidal ideation", "flat affect") and in the course of the evaluation, we will recognize that the underlying syndrome is delirium and make recommendations for management of associated symptoms (e.g. agitation, hallucinations, delusions) and will recommend general behavioral recommendations and further workup.

Imaging is not typically part of the evaluation of delirium, with some notable exceptions. But we certainly don't (and shouldn't) scan every confused geriatric patients. In younger patients with altered mental status imaging may be useful.

In some institutions neurology is very involved in delirious patients, but this is the exception rather than the rule.

For complex cases input from multiple specialties including neuro, psych, ID, rheum, nephrology is essential.

Psychiatry can also help when there is a "psychiatric" etiology to the presentation, e.g. serotonin toxicity, neuroleptic malignant syndrome, Ganser syndrome, factitious disorder, hysteria, hystero-psychosis, factitious disorder, malingering, catatonia, delirium-catatonia, acute polymorphic psychotic disorder, boufée délirante and so on.
 
Typically psychiatry is not involved in the work up of delirium (but we should be and by necessity may need to be if the patient is misdiagnosed or mismanaged). It would be very unusual for psychiatry to be consulted for workup and management of delirium explicitly. In fact it almost never happens unless its a really bad hospital. Instead, psychiatry is consulted for another reason (e.g. "rule/out late onset schizophrenia", "management of agitation", "decision making capacity", "patient trying to leave AMA", "suicidal ideation", "flat affect") and in the course of the evaluation, we will recognize that the underlying syndrome is delirium and make recommendations for management of associated symptoms (e.g. agitation, hallucinations, delusions) and will recommend general behavioral recommendations and further workup

I don't think the above is true. Where I trained (a major metro academic center) had consults on delirium management all the time. Obviously they would handle the medical part of it, but behavioral management was a very common consult and involved reviewing imaging (if there was any), labs, medical hx, etc. But where I was had a very large psych presence and it was common to work with medical teams.
 
Typically psychiatry is not involved in the work up of delirium... It would be very unusual for psychiatry to be consulted for workup and management of delirium explicitly...
Instead, psychiatry is consulted for another reason (e.g. ..."management of agitation"
I don't think the above is true. Where I trained (a major metro academic center) had consults on delirium management all the time. Obviously they would handle the medical part of it, but behavioral management was a very common consult
I don't think you're actually disagreeing.
 
I don't think you're actually disagreeing.

Maybe I misunderstood the post, but I thought what Splik was saying is that we get consulted for what they think is psych (r/o schizophrenia, decision-making capacity, SI) and we recognize it's actually delirium and make recommendations. In my experience, we get "delirium" consults all the time with nothing more than "delirium management" as the question. It's almost a reflex for some teams - delirium? Get psych consult!
 
Typically psychiatry is not involved in the work up of delirium (but we should be and by necessity may need to be if the patient is misdiagnosed or mismanaged). It would be very unusual for psychiatry to be consulted for workup and management of delirium explicitly. In fact it almost never happens unless its a really bad hospital.

Thanks for the explanation splik, but I'm just curious about this part: you said that psychiatrists should be more involved in the work up of delirium, but any hospital that consults them explicitly for delirium is a really bad hospital. Could you clarify what you mean by that?

I don't think the above is true. Where I trained (a major metro academic center) had consults on delirium management all the time. Obviously they would handle the medical part of it, but behavioral management was a very common consult and involved reviewing imaging (if there was any), labs, medical hx, etc. But where I was had a very large psych presence and it was common to work with medical teams.

I was thinking about a case I heard about not long ago: HIV+ patient that came to the ER with a fever and agitation. Psych was called, and after recommending medication, labs and head CT, they suggested consulting neuro for them to pick things up from there. I was kinda thrown off by this, because even though I don't care about strokes and seizures and whatnot, I thought Psych would do a bit more sleuthing in cases that involved mental status alterations, and decided to know if this is more of an institucional thing or not.
 
I was thinking about a case I heard about not long ago: HIV+ patient that came to the ER with a fever and agitation. Psych was called, and after recommending medication, labs and head CT, they suggested consulting neuro for them to pick things up from there. I was kinda thrown off by this, because even though I don't care about strokes and seizures and whatnot, I thought Psych would do a bit more sleuthing in cases that involved mental status alterations, and decided to know if this is more of an institucional thing or not.
Psych isn't going to do the LP.
 
I was thinking about a case I heard about not long ago: HIV+ patient that came to the ER with a fever and agitation. Psych was called, and after recommending medication, labs and head CT, they suggested consulting neuro for them to pick things up from there. I was kinda thrown off by this, because even though I don't care about strokes and seizures and whatnot, I thought Psych would do a bit more sleuthing in cases that involved mental status alterations, and decided to know if this is more of an institucional thing or not.

In the case of my hospital, we would recommend involving neuro, but we'd stay on as well until the patient was more stable. That doesn't mean we'd see the patient every day, but we'd do chart review and follow up as needed.
 
In residency we would have 3 specialties that would often be consulted for delirium.

Neurology would typically recommend treating the primary cause and sign off... or recommend a million dollar workup. 50/50 shot.
Psychiatry would recommend agitation PRNs and take care of behavioral codes overnight.
Geriatrics would recommend homeopathic doses of PRNs despite frequent behavioral codes that psychiatry had to manage overnight.

Typically we (psychiatry) would sign off the second any other specialty started making delirium recommendations. Otherwise it's too many cooks in the kitchen.
 
As a consultant, I try to sign off as soon as I determine it is delirium and is not primarily a psychiatric cause as a consultant. My primary goal is to answer whether this is psychiatric or not, recommend behavioral and medication options, and get out. I will generally only follow up once unless it is truly psychiatric or complex/idiopathic. I avoid writing any orders at all unless urgent for safety and only make recommendations to the primary physician (usually the IM hospitalist or surgeon.) Otherwise, I find that the treatment team in many hospitals will often try to make me the primary doctor and even turf the patient to psychiatric inpatient and call me at all hours to manage the patient. I have my own patients and am not a full time C&L psychiatrist, so that is a no go. I nearly quit my current job in part because the hospital expected me to be a full time C&L psychiatrist in addition to a full time outpatient load.

I dont even want to get started on IM /family/surgery residents who consult every specialist the minute a patient hits the ER, or other doctors who think I'm a social worker.
 
At the hospitals in my training program, what @splik mentioned in terms of misdiagnosis is a common cause for being consulted about delirium. Rarely is a consult to psychiatry made to actually diagnose a suspected case of delirium. Usually the diagnosis is made and the patient is being behaviorally difficult, resulting in a psychiatry consult with a request for input on managing agitation. While @adiradirim was probably being tongue-in-cheek in his post, frankly that's not far from reality.
 
Maybe I misunderstood the post, but I thought what Splik was saying is that we get consulted for what they think is psych (r/o schizophrenia, decision-making capacity, SI) and we recognize it's actually delirium and make recommendations. In my experience, we get "delirium" consults all the time with nothing more than "delirium management" as the question. It's almost a reflex for some teams - delirium? Get psych consult!
Splik did say those things, but the item I specifically quoted was management of agitation. In those cases, we're not consulted in order to work up delirium but instead manage the behavioral effects of it, which is what you said.
 
Splik did say those things, but the item I specifically quoted was management of agitation. In those cases, we're not consulted in order to work up delirium but instead manage the behavioral effects of it, which is what you said.

So perhaps I should have bolded specifically what I disagreed with.
 
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